Introduction

1. Ophthalmic EvaluationHistory taking& ExaminationTurki Al-Turki, MDConsultant OphthalmologistKing Saud Medical CityRiyadh

2. Introduction The eye is the most precious square inch of the body Biological window Tells about the health and disease of the invisible organs by simply looking through them. Eye is the only part of the body where Blood vessels & Central nervous system tissues can be viewed directly. Hence, Mastering ophthalmic history taking & examination, enables early detection of many diseases.

3. History taking • Demographic data. • Chief complaint. • Present illness. • Past ocular history. • Ocular medications. • General medical & surgical history. • Systemic medications. • Allergies. • Social history. • Family history.

4. History taking Demographic Data • Name • Age • Gender • Race • Occupation Chief complaint Present illness Past ocular history Ocular medications General medical & surgical history Systemic medications Allergies Social history Family history Department & staff

5. History taking Demographic Data • Name • Age • Gender • Race • Occupation Chief complaint Present illness Past ocular history Ocular medications General medical & surgical history Systemic medications Allergies Social history Family history Department & staff

6. History taking Demographic Data • Name • Age • Gender • Race • Occupation Chief complaint Present illness Past ocular history Ocular medications Variable of human races had variable disease prevalence Caucasians  Age related macular degeneration. Asian  Behcet’s Disease. General medical & surgical history Systemic medications Allergies Social history Family history Department & staff

7. History taking • Certain disease prevalence Demographic Data • Name • Age • Gender • Race • Occupation Chief complaint Present illness Past ocular history Ocular medications • Decide for surgery General medical & surgical history • Recognize patients at risk Systemic medications Allergies Social history Family history Department & staff

8. History taking Demographic Data Chief complaint • Say • “Redness” • “Flashes of light” • “tearing” Present illness • Patient’s own words Past ocular history Ocular medications General medical & surgical history Don’t say “Conjunctivitis” “Photopsia” “Epiphora” Systemic medications Allergies Social history Family history Department & staff

9. History taking Demographic Data • Time and manner of onset • Sudden or gradual. • Duration. • For how long? • Severity & fluctuation • problem improved, worsened, or remained the same? • Influences • What precipitated the condition? • Variability • Intermittent or seasonal, or worsen at a particular time of day? • Associated systemic complaint • N&V, Back pain, Tinnitus, parasthesia • Laterality • Unilateral or bilateral? Chief complaint Present illness Past ocular history Ocular medications General medical & surgical history • Documentation • Previous record  saves time &efforts. • Glass prescriptions  Keratoconus • Old photos  proptosis, ptosis Systemic medications Allergies Social history Family history Department & staff

10. History taking Demographic Data Chief complaint • Documentation • Previous record  Saves time &efforts. • Glass prescriptions  Keratoconus • Old photos  proptosis, ptosis • Optic nerve photo  Glaucoma Present illness Past ocular history Ocular medications General medical & surgical history Systemic medications Allergies Social history Family history Department & staff

11. History taking Demographic Data Chief complaint • Use of eyeglasses or contact lenses • Date of the most recent prescription • Ocular surgery (including laser surgery) • Ocular trauma • Eye patching in childhood(Amblyopia) Present illness Past ocular history Ocular medications General medical & surgical history Systemic medications Allergies Social history Family history Department & staff

12. History taking Demographic Data • Knowledge of the patient's use of ocular medications is essential for • two reasons: • 1. How the patient responded to prior therapy. • 2. Recent therapy (within the past 6 weeks) can affect the patient's present status. • Dosages • Frequency • Duration of use. • Also ask about the use of any over-the-counter (nonprescription) medications and home remedies. Chief complaint Present illness Past ocular history Past ocular history Ocular medications General medical & surgical history Systemic medications Allergies Social history Family history Department & staff

13. History taking Some patients don’t know their drops They may be recognized by the top cover Demographic Data Chief complaint Present illness Past ocular history Ocular medications Ocular medications General medical & surgical history Systemic medications Allergies Social history Family history Department & staff

14. History taking Demographic Data Chief complaint Present illness Past ocular history Past ocular history • 1. Many ocular diseases are in associated with systemic diseases. • 2. Important part of pre-operative evaluation. • Full systemic review is essential. • Pediatric patients may require full antenatal and postnatal history Ocular medication General medical & surgical history Systemic medications Allergies Social history Family history Department & staff

15. History taking Demographic Data Chief complaint Present illness Past ocular history Past ocular history Ocular medication • In addition to providing clues to the systemic disorders • Systemic medications can cause • Ocular changes • (IOP) • Pre-operative changes • (Coagulopathy) • Intra-operative changes • (Floppy iris syndrome) General medical & surgical history Systemic medications Allergies Social history Family history Department & staff

16. History taking Demographic Data Chief complaint Present illness Past ocular history Past ocular history Ocular medication General medical & surgical history • Systemic as well as topical therapy. • It has to be documented in the file. • Systemic allergy query to detect individuals with atopy. • Special attention medications known to cause allergies • (e.g. Timilol, PG analogs, Atropine) Systemic medications Allergy Social history Family history Department & staff

17. History taking Demographic Data Chief complaint Present illness Past ocular history Past ocular history Ocular medication General medical & surgical history • Tobacco • Drugs • Sexual contact • Alcohol • Level of education & socioeconomic status • ( compliance to therapy) Systemic medications Allergies Social history Family history Department & staff

18. History taking Demographic Data Chief complaint Present illness Past ocular history Past ocular history Ocular medication • Genetically transmitted diseases (CHED) • Familial ocular diseases (Myopia, Keratoconus) • Family history of cataract, glaucoma, corneal diseases. • Family history of systemic diseases • (Atopy, Thyroid disease, DM, certain malignancies, various hereditary syndromes, and many others. General medical & surgical history Systemic medications Allergies Social history Family history Family history Department & staff

20. Ocular Examination

21. Ocular Examination • Visual acuity. • External examination. • Motility and alignment • Pupil examination • Tonometry. • Slit lamp biomicroscopy • Ophthalmoscopy • Gonioscopy • Retinoscopy & refraction

22. Ocular Examination 1.Visual acuity test Distant Vs. Near What is 20/20? What is 6/6?

23. Ocular Examination • Visual acuity test Corrected Vs. Uncorrected Children visual acuity (Infants, toddlers, verbal kids) What is pinhole?

24. Ocular Examination Testing people with poor vision If the patient is unable to read the largest letter then his vision is < (20/200) (Legal Blindness) Start evaluating by your hands and record the distance - Count fingers (CF) - Hand motion (HM) If unable to see the movement, then test with light source - Light perception (LP) comment on projection - No light perception (NLP)

25. Ocular Examination External inspection Know how normal looks like first !!

26. Ocular Examination Then you can recognize the abnormal!!

27. Ocular Examination Inspect the lid position & contour Look at eyelashes and observe blinking. Anterior segment structures.

28. Ocular Examination • Ocular Adnexa. (lids & periocular area)

29. Ocular Examination • Evaluate by gross inspection and palpation. • Skin lesions, growths, inflammatory lesions. • Lymph node examination (Pre-auricualr, Sub-mandibular) • Is there any proptosis?

30. Ocular Examination Observe Ocular motility at all directions of gaze

31. Ocular Examination What is the problem?

32. Ocular Examination Alignment (Hirschberg's test)

33. Ocular Examination False strabismus (pseudo-strabismus)

34. Ocular Examination • Red reflex Bilateral No misalignment. Symmetrical No media opacity. Bright No refractive error.

35. Ocular Examination • Red reflex Bilateral ? misalignment. Symmetrical ? media opacity. Bright ? refractive error.

36. Ocular Examination • Red reflex

37. Ocular Examination The Pupil

38. Ocular Examination Pupils Size Color Shape

39. Ocular Examination Direct light reflex Consensual light reflex

42. Ocular Examination Ishihara color vision chart 15/15

43. Ocular Examination Intra-ocular Pressure measurement (Tonometry) Normal range (10-21 mmHg) Several devices: • Applanation tonometers Schiotz Goldman Perkins

44. Ocular Examination 2.Pneumo-tonometer 3. Air puff tonometer

45. Ocular Examination • Tonopen

46. Ocular Examination Direct Ophthalmoscope • Upright image • 15 times magnification • Can be used by any medical personnel.

47. Ocular Examination Indirect Ophthalmoscope • Real, inverted image • Needs special training to master. • Condensing lenses are needed • Wider field.

48. Ocular Examination Is a table-mounted binocular microscope with special illumination source. A linear slit beam of light is projected onto the globe – optical cross section of the eye. Portable device is also available.

50. Ocular Examination